Cognitive Behavioural Therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: A randomised controlled trial

Tinnitus is the perception of a sound in the absence of an external noise.  It is a very prevalent experience; studies vary slightly but it is generally accepted that tinnitus affects between 10% and 15% of the population.  Tinnitus can affect all age groups, including children, but a person is more likely to experience it as they age.  With an aging population tinnitus is likely to become more of an issue.  While for many people tinnitus is not distressing, in others it is accompanied by anxiety and depression, concentration problems, auditory perceptual difficulties and insomnia.  Insomnia is characterised by regular, sustained difficulties in getting to sleep, staying asleep, waking too early and being unsatisfied with sleep.  Day-time effects of insomnia include difficulties with fatigue, attention, memory and mood.  Insomnia is reported by up to 40% of people attending tinnitus clinics; this is 3 to 4 times the population average.  Some studies suggest that insomnia is the most important aspect of tinnitus complaint.  People with tinnitus who also experience insomnia tend to rate their tinnitus as much worse than people who sleep well.  One important question is cause and effect.  Do people sleep badly because they have worse tinnitus or is tinnitus worse because they sleep badly?  Despite the size and importance of the problem there has been relatively little research into tinnitus related insomnia.

One thing that has emerged from the limited research is that tinnitus related insomnia has the same characteristics as insomnia disorder (insomnia in the absence of tinnitus distress).  That is, anyone with insomnia tends to report enormous worry about not sleeping sufficiently well.  This suggests that tinnitus related insomnia might respond to the same treatments that are helpful for other forms of insomnia.  The most effective treatment for insomnia is Cognitive Behavioural Therapy for Insomnia (CBTi), which targets cognitive behavioural maintenance factors, such as worry about not sleeping enough and behaviours adopted to recover lost sleep which could end up worsening sleep further, such as spending excessive time in bed.  CBTi has been found to be helpful for people with insomnia both alone and alongside other health conditions, notably chronic pain.  Inspired by that we offered patients in our clinic six sessions of group-based CBTi treatment for tinnitus-related insomnia and observed clinically significant improvements in insomnia, tinnitus distress and psychological distress. 

This led us to conduct a randomised controlled trial of six sessions of group-based CBTi for tinnitus related insomnia.  The aim was to test, in controlled conditions, whether CBTi reduces insomnia that occurs in the presence of tinnitus. We also wanted to test whether CBTi for patients with tinnitus, could lead to a better outcome than existing, standard care for this patient group.  We therefore compared group-based CBTi for tinnitus-related insomnia with the standard care that patients in audiology centres receive.  While standard care varies widely, it rarely involves more than two sessions and includes education, supportive counselling, advice about relaxation and sleep hygiene from an audiologist.  To exclude the possibility that the two interventions work simply because of the social contact involved (i.e. six sessions of CBTi vs two sessions of standard care) we also compared CBTi to six sessions of a support group. In the support group, people discussed their tinnitus and insomnia but with none of the active or specific components of CBTi or standard care were covered. Participants were recruited at the Royal National ENT Hospital in London or through advertisements.

Just over 100 people with insomnia and tinnitus took part in the study and were offered one of the three groups. Following the intervention, people in the CBTi groups were observed to suffer less insomnia, as assessed using a standardised measure, than people who received only standard care; in turn the standard care was more effective at reducing insomnia than social support.  These differences were still present six months post treatment, at which point the study finished.  A similar pattern of effect was seen for psychological distress, with CBTi having the largest improvement.  After six months, people who received CBTi or standard care also slept longer, as assessed using sleep logs, than those who had received only social support.  What this study shows is that the care offered to patients with insomnia and tinnitus in audiological centres is effective, but that significantly larger benefits may be achieved for patients offered CBTi, the intervention that specifically targets how people think and feel about insomnia, and the ineffective ways in which they react to it.  

An important aspect of this work is that the therapeutic focus was on insomnia, rather than tinnitus, and that it led to improvements in both insomnia and tinnitus distress. It is important, however,  to note that some of the key elements used in CBTi are also found in cognitive behavioural therapies for tinnitus (e.g. psychoeducation, stress management skills such as applied relaxation, dealing with negative thoughts etc). Furthermore, feedback from patients completing CBTi indicated how much they valued being part of a group with people who shared and understood their experiences. As such, this study cannot offer clarity regarding the question about the direction of cause and effect between tinnitus and insomnia (in all likelihood there is some circularity), but it does offer hope to patients and clinicians that if they can find effective ways of improving sleep and reducing insomnia, there may well be a positive improvement in their tinnitus distress as well. 

Read the full paper: Marks, E., Hallsworth, C., Vogt, F., Klein, H., & McKenna, L. (2022). Cognitive behavioural therapy for insomnia (CBTi) as a treatment for tinnitus-related insomnia: A randomised controlled trial. Cognitive Behaviour Therapy, 1-19.

Blog Article Authors: Florian Vogt, Laurence McKenna, Elizabeth Marks

Photo by: Alyssa L. Miller

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